Etiologic Considerations in the Patient With Syncope and an Apparently Normal Heart

Goldschlager, Nora; Epstein, Andrew E.; Grubb, Blair P.; Olshansky, Brian; Prystowsky, Eric N.; Roberts, William C.; Scheinman, Melvin M.

doi:10.1001/archinte.163.2.151

Cited by 46 publications

(23 citation statements)

References 38 publications

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“…8,9 Questions related to abruptness of onset, peri-syncope symptoms, and exacerbating or attenuating factors are helpful. The patient's history and presentation should guide testing (fi g. 1).…”

Section: Workup For Syncopementioning

confidence: 99%

“…1,13,40 Under normal circumstances, there is a gravity-mediated downward displacement of approximately 300 to 800 mL of blood, representing a volume drop of 25%-30%, to the vasculature of the abdomen and lower extremities. 41 Successful maintenance of upright posture and hemodynamic stability is dependent on a complex interplay of neurohormonal changes, baro-and mechano-receptors, and circulatory changes.…”

Section: Orthostatic Hypotension (Oh)mentioning

confidence: 99%

“…An abnormality in the gene SCN5A encoding the α subunit of the cardiac sodium channel gene causes the syndrome. 1,90,91,93 The ECG changes may be dynamic and can be potentiated by administering sodium channel blocking drugs such as procainamide or fl ecainide.…”

Section: Brugada Syndromementioning

confidence: 99%

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Evaluation and Management of Syncope

Bindra

Marchlinski

Lin

2008

Clinical medicine. Circulatory, respiratory and pulmonary medic

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Context Syncope is a commonly encountered by primary care physicians and cardiologists. Etiology is frequently not apparent, and patients may undergo unnecessary tests. Treatment must be tailored to the likely etiology. Complexities of diagnosis and treatment often warrant referral to a specialist. Objective To highlight the evolving recommendations for managing syncope in a clinically and cost effective manner. Evidence Acquisition An electronic literature search was undertaken of the Medline database from January 1996 to April 2006, using the Medical Subject Heading syncope, defibrillators, pacemakers, echocardiogram, cardiomyopathy, long QT syndrome, Arrhythmogenic right ventricular dysplasia, and Brugada syndrome. Abstracts and titles were reviewed to identify English-language trials. Bibliographies from the references as well as scientific statements from the Heart Rhythm Society, American Heart Association, and American College of Cardiology were reviewed. Evidence Synthesis A methodical approach to syncope can improve diagnosis, limit testing, and identify patients at risk of fatal outcome. A thorough history, physical exam and electrocardiogram are critical to the initial diagnosis. Presence of heart disease determines the extent of work-up and treatment. A trans-thoracic echocardiogram should be performed in patients with an unclear diagnosis and a positive cardiac history or an abnormal ECG. Ventricular arrhythmias are the most common cause of syncope in patients with structural heart disease. Patients with an ejection fraction less than 30 percent should receive an implantable defibrillator with few exceptions. An electrophysiology study may assist risk stratification in syncopal patients with borderline ventricular function. In patients without structural heart disease, the presence of a well defined arrhythmia syndrome consistent with a genetically determined risk of sudden death must be sought. The 12-lead electrocardiogram, family history and clinical presentation will identify most high-risk patients. Patients without structural heart disease can often be managed conservatively with well defined strategies for preventing neurocardiogenic syncope. Conclusions Managing syncope requires a methodical approach. An understanding of the limitations of the diagnostic tools and treatments is important. Lethal causes of syncope make it imperative to recognize the appropriate timing of referring patients to specialists.

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Section: Workup For Syncopementioning

confidence: 99%

Section: Orthostatic Hypotension (Oh)mentioning

confidence: 99%

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Evaluation and Management of Syncope

Bindra

Marchlinski

Lin

2008

Clinical medicine. Circulatory, respiratory and pulmonary medic

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“…It is characterized by a sudden failure of the autonomic nervous system to maintain blood pressure and heart rate at a level sufficient to obtain cerebral perfusion and consciousness [1]. Recurrent episodes of VVS can result in injury and may provoke substantial anxiety and a degree of functional impairment among patients [2, 3]. However, the treatment of VVS still remains a therapeutic challenge.…”

Section: Introductionmentioning

confidence: 99%

Minor Psychiatric Disorders and Syncope: The Role of Psychopathology in the Expression of Vasovagal Reflex

Leftheriotis

Michopoulos²,

Flevari³

et al. 2008

Psychother Psychosom

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Background: A high prevalence of minor psychiatric disorders (MPDs) has been reported in patients with vasovagal syncope (VVS). However, the relationship between the psychiatric substrate and syncope remains unclear. Methods: In order to test the hypothesis that MPDs may predispose to VVS, we assessed the prevalence of syncope, the response to head-up tilt test (HUTT) and the efficacy of psychiatric drug treatment in reducing syncopal episodes, in patients with recently diagnosed MPDs. The response to HUTT was compared with that in an equal number of matched (a) patients with VVS and (b) healthy controls. Results: A high rate of patients with MPDs (58%) had a positive HUTT. Additionally, 45% had a history of syncope; among them, the rate of positive HUTT was identical to that in the VVS group (83%). Following psychiatric drug treatment, the number of patients with syncope decreased in the MPD group (6/67 from 30/67, p < 0.01). Psychiatric symptoms and quality of life were also improved. The number of syncopal spells decreased equally in the MPD and VVS groups (0.6 ± 0.5 from 2.5 ± 1.4, p < 0.01, and 0.7 ± 0.5 from 2.7 ± 1.3, p < 0.01, respectively). Conclusion: A high proportion of patients with MPDs experience syncope, associated with a high rate of positive HUTT, comparable to that observed in VVS. Psychiatric treatment results in the improvement of syncopal and psychiatric symptoms. These findings suggest involvement of co-occurring MPDs in the pathogenesis of VVS. Therefore, the diagnosis and treatment of MPDs, when present, may be crucial for the effective therapy of vasovagal syndrome.

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“…Syncope is one of the paroxysmal clinical events consi dered in the differential diagnosis of epilepsy, especially DRE. It is defined as episodes of transient loss of consciousness, with relatively sudden onset and loss of postural tone, fol lowed by spontaneous and complete recovery, without per sistent neurological signs, that does not require chemical or electrical cardioversion 6,7 . It is estimated that 20-30% of pa tients with epilepsy have other causes for loss or disturbance of consciousness, even those monitored in centers for epi lepsy treatment 8 .…”

mentioning

confidence: 99%

Syncope in patients with drug-resistant epilepsy without apparent cardiovascular disease

Alves-Leon

Pinto

Andraus

et al. 2013

Arq. Neuro-Psiquiatr.

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Epilepsy and syncope are clinical conditions with high prevalence rates in the general population, and the differential diagnosis between them is difficult. Objective: To assess the frequency of syncope in patients diagnosed with drug-resistant epilepsy (DRE) without apparent heart disease, to investigate the relationship between clinical and electroencephalographic (EEG) changes, and to verify the role of the inclination test (IT (n=9), with a significant prevalence in women. Vasovagal syncope (VVS) was the most frequent diagnosis. Conclusion: We found a significant association between syncope and the presence of autonomic symptoms (p=0.005). The IT plays an important role in the differential diagnosis of patients with DRE presenting with autonomic symptoms, regardless of EEG results and brain magnetic resonance imaging (MRI) abnormalities.Keywords: drug-resistant epilepsy, epilepsy, inclination test, syncope, pseudoseizures. RESUMOEpilepsia e síncope são condições clínicas com alta prevalência na população geral e, às vezes, o diagnóstico diferencial entre elas é difícil. Objetivo: Investigar a frequência de síncope em pacientes diagnosticados com epilepsia fármaco resistente (EFR), sem doença cardíaca aparente; investigar a relação entre alterações clínicas e eletrencefalográficas; verificar o papel do teste de inclinação (TI). Método: Estudo aberto prospectivo, realizado de 2004 a 2006, incluindo 35 pacientes consecutivos do Programa de Epilepsias do Hospital Universitário Clementino Fraga Filho, diagnosticados com EFR, sem doença cardíaca aparente. Resultados: A frequência de síncope foi de 25,7% (n=9), com prevalência significativa em mulheres. Síncope vasovagal (SVV) foi o diagnóstico mais frequente. Conclusão: Encontramos uma significativa associação entre síncope e a presença de sintomas autonômicos (p=0,005). O TI tem importante papel no diagnóstico diferencial de pacientes com diagnóstico de EFR que apresentam sintomas autonômicos, a despeito de alterações eletrencefalográficas e de ressonância magnética do crânio.Palavras-chave: epilepsia fármaco-resistente, epilepsia, teste de inclinação, pseudocrises.

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Etiologic Considerations in the Patient With Syncope and an Apparently Normal Heart

Cited by 46 publications

References 38 publications

Evaluation and Management of Syncope

Evaluation and Management of Syncope

Minor Psychiatric Disorders and Syncope: The Role of Psychopathology in the Expression of Vasovagal Reflex

Syncope in patients with drug-resistant epilepsy without apparent cardiovascular disease

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